MAURI EXPERTA
MANAGEMENT COMPANY
CLIENT ACCEPTANCE FORM
STRICTLY PRIVATE AND CONFIDENTIAL
This Client Acceptance Form is an Agreement between Mauri Experta Ltd and you. The information required to complete the Form will ensure that Mauri Experta Ltd complies with all legal requirements in Mauritius. The information you supply will remain confidential unless Mauri Experta Ltd is required by Law or by an order of a Court of competent jurisdiction to disclose it.
If you wish to receive mail at 'other', please provide details:
SECTION 1 (PERSONAL DETAILS)
Place of Birth
Marital Status
Passport Number(s)
Nationality(ies)
Expiry date
-
Month
-
Day
Year
Date
Full Name (Title, name, middle name, surname)
First Name
Last Name
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SECTION 2 (REFERENCES)
Mauri Experta Ltd is required to obtain references prior to accepting any new client. The following information is required from a banker:
Home Telephone Number (including country and area code)
Format: (000) 000-0000.
Name and Address of your Banker
Home Facsimile Number (including country and area code)
Format: (000) 000-0000.
Telephone Number (including country and area code)
Format: (000) 000-0000.
E-mail Address
example@example.com
Home Facsimile Number (including country and area code)
Format: (000) 000-0000.
Occupation
E-mail Address
example@example.com
Office Telephone Number (including country and area code)
Format: (000) 000-0000.
Office Facsimile Number (including country and area code)
Format: (000) 000-0000.
Please indicate whether you wish to receive mail at your home, office or other address:
Home
Office
Other
Initials
Mauri Experta Ltd | Office 2, Level 4, ICONEBENE, Lot B441, Rue de L'Institut, Ebene, Mauritius Tel: +230 466 6100 | Fax: +230 468 1221 Email: info@mauriexperta.com | Web: www.mauriexperta.com | BRN: C10099206 Management Licence Number: MC11000113 | Regulated by the Mauritius Financial Services Commission
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MAURI EXPERTA
MANAGEMENT COMPANY
CLIENT ACCEPTANCE FORM
SECTION 3 (REPUTATION AND GOOD CHARACTER)
A. Have you or any corporation in which you are or have been associated with at any time, been convicted of any offence including spent matters by any Court in any jurisdiction? If so, give full particulars of the Court by which you were convicted, the offence and the penalty imposed and the date of conviction. (Road Traffic offences should not be listed).
YES
NO
(Please tick as appropriate). If yes, please give full particulars.
B. Have you, or any corporation with which you are or have been associated:(a) been the subject of any punitive action;(b) been refused a licence or equivalent authorisation to carry on a business activity;(c) have had a licence or equivalent authorisation to carry on a business activity revoked;(d) been censured, disciplined or publicly criticised or adversely commented upon and(e) is, or has been the subject of any investigation and/or enquiry by any professional body or any public body or any Regulatory Authority?
YES
NO
(Please tick as appropriate). If yes, please give full particulars.
C. Have you ever been adjudicated bankrupt by any Court or entered into a compromise or arrangement with creditors?
YES
NO
(Please tick as appropriate). If yes, please give full particulars.
D. Have you ever failed to satisfy any debt adjudged due and payable by you as a judgment debtor under an order of a court in any jurisdiction?
YES
NO
(Please tick as appropriate). If yes, please give full particulars.
Initials
2
Mauri Experta Ltd | Office 2, Level 4, ICONEBENE, Lot B441, Rue de L'Institut, Ebene, Mauritius
Tel: +230 466 6100 | Fax: +230 468 1221 | Email: info@mauriexperta.com | Web: www.mauriexperta.com | BRN: C10099206
Management Licence Number: MC11000113 | Regulated by the Mauritius Financial Services Commission
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MAURI EXPERTA
MANAGEMENT COMPANY
CIENT ACCEPTANCE FORM
E. Has any corporation with which you have been associated been compulsorily wound up or has been subject to voluntary winding up, or made any compromise or arrangement with its creditors, or ceased trading?
YES
NO
(Please tick as appropriate). If yes, please give full particulars.
F. Are you engaged in any personal litigation with respect to the management of any business corporation?
YES
NO
(Please tick as appropriate). If yes, please give full particulars.
G. Have you ever, at any time, been the subject of an investigation in relation to a corporation, including a financial institution?
YES
NO
(Please tick as appropriate). If yes, please give full particulars.
H. Have you ever been disqualified from acting as a director or similar position? Have you ever, at any time, been the subject of an investigation in relation to a corporation, including a financial institution?
YES
NO
(Please tick as appropriate). If yes, please give full particulars.
Initials
3
Mauri Experta Ltd | Office 2, Level 4, ICONEBENE, Lot B441, Rue de L'Institut, Ebene, Mauritius
Tel: +230 466 6100 | Fax: +230 468 1221 Email: info@mauriexperta.com | Web: www.mauriexperta.com | BRN: C10099206
Management Licence Number: MC11000113 | Regulated by the Mauritius Financial Services Commission
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MAURI EXPERTA
MANAGEMENT COMPANY
CLIENT ACCEPTANCE FORM
I. Do you have any written complaints made against you by clients or former clients in the last five years which you have accepted, or which are awaiting determination, or have been upheld - by an Ombudsman or complaints scheme?
YES
NO
(Please tick as appropriate). If yes, please give full particulars.
J. Have you ever been refused entry to, or been dismissed, suspended or requested to resign from, any professional, vocation, office or employment, or from any fiduciary office or position of trust whether or not remunerated?
YES
NO
(Please tick as appropriate). If yes, please give full particulars.
K. Have you ever, anywhere, been censured, disciplined or criticised by any professional body to which you belong or have belonged to?
YES
NO
(Please tick as appropriate). If yes, please give full particulars.
Initials.
Mauri Experta Ltd | Office 2, Level 4, ICONEBENE, Lot B441, Rue de L'Institut, Ebene, Mauritius
Tel: +230 466 6100 | Fax: +230 468 1221 Email: info@mauriexperta.com | Web: www.mauriexperta.com | BRN: C10099206
Management Licence Number: MC11000113 | Regulated by the Mauritius Financial Services Commission
MAURI EXPERTA
MANAGEMENT COMPANY
CLIENT ACCEPTANCE FORM
SECTION 4 (INDIVIDUAL SELF-CERTIFICATION FORM)
TAX RESIDENCY
Mauri Experta Ltd is required by tax regulations¹ to collect information about each client tax residency². In certain circumstances (including if we do not receive a valid self-cer-tification from you), Mauri Experta Ltd may be required to share information about you with the Mauritius Revenue Authority, the local tax authority, which may in turn share this information with any or all participating tax jurisdictions³.
Please indicate all countries in which you are resident for tax purposes and your associated Tax Identification Number(s) in the table below. If you are also a US citizen you must include the United States in this table along with your US Tax Identification Number.
You are not required to provide details of your Tax Identification Number or date of birth where you are tax resident only in Mauritius.
If you have any questions about your tax residency, please contact your tax adviser.
Rows
COUNTRY/COUNTRIES OF TAX RESIDENCY
TAX IDENTIFICATION NUMBER
1
2
3
4
Please indicate any of the following which is applicable to you:
Are you a U.S. citizen?
Yes
No
Do you have a U.S. place of birth?
Yes
No
Do you have a currently effective power of attorney or signatory authority granted to a person with a U.S. address?
Yes
No
Do you have any current US residence address or U.S. mailing address (including a U.S. post office box)?
Yes
No
Do you have an 'in-care-of' U.S. address or 'hold mail' U.S. address that is your sole address or the sole address provided for the entity?
Yes
No
Do you have standing instructions to transfer funds to an account maintained in the U.S.?
Yes
No
Initials
5
Mauri Experta Ltd | Office 2, Level 4, ICONEBENE, Lot B441, Rue de L'Institut, Ebene, Mauritius Tel: +230 466 6100 | Fax: +230 468 1221 | Email: info@mauriexperta.com | Web: www.mauriexperta.com | BRN: C10099206 Management Licence Number: MC11000113 | Regulated by the Mauritius Financial Services Commission.
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